Case Study: Pain Program Outcome

Authors: Dan Flanagan & Dylan Woodward

As a return-to-work provider, we sometimes encounter injured workers receiving less than optimal treatment to address their functional needs.     

I was recently involved in a case where this problem was encountered. Fortunately, the worker acknowledged their lack of improvement and was open to the possibility of an alternate approach.  This led to potentially the greatest change of outcomes I have seen yet in my career.  

The Situation: 

Middle aged school cleaner sustained a thumb injury during a fall at work.  

A return-to-work provider was engaged after 4 months, due to a recent regression in capacity due to ongoing pain and disability.  

Scans had indicated a minor subluxation of their thumb ulnar collateral ligament and some mild osteoarthritic changes in the thumb joint. The worker reported the understanding of their condition to be an “unstable thumb joint.”  A hand therapist was managing their treatment and had been unable to progress the worker past basic range of motion exercise due to high levels of pain. The worker had also been encouraged to support their thumb using a rigid splint – which they wore daily. As such, the worker generally avoided any use of their affected hand due to pain.  

We were only able progress work duties along at a very gradual pace over the next couple of months. Unfortunately, we saw no changes to reported pain and no changes in the rehabilitation approach, with ongoing continual use of a thumb splint.  The worker reported the treatment messages they continued to receive were “your thumb is still unstable” and “we need it to settle.”  

Furthermore, an orthopedic surgical specialist was also engaged and after two unsuccessful cortisone injections, it was proposed by both the hand therapist and specialist, that a fusion surgery may be the only option to reduce pain due to their lack of improvement with conservative care.  However, the worker was advised this would result in a permanent reduction in hand function that would affect a livelihood which relied upon physical use of the hand.   

Axis Intervention: 

The worker and their insurer were on board with considering a different approach due to the poor prognosis and the gravity of impending surgery.   

A Screening Assessment was approved with one of Axis’s expert pain management Physiotherapists. 

After a thorough assessment, it was determined the injured worker’s thumb demonstrated no obvious signs of physical instability. Instead, it was identified their thenar muscles were incredibly deconditioned and hypersensitive to movement and load, likely compounded by unhelpful pain beliefs and cognitions. It was also determined the treatment and home exercise program to date had failed to appropriately address any functional needs of the individual. Furthermore, it had failed to evoke any form of self-confidence in the worker’s physical capacity.    

The worker was recommended to undertake an Axis Pain Management and Functional Rehabilitation Program, attending sessions twice weekly over a 6-week period.  Treatment was personalised and multimodal, aimed at challenging maladaptive beliefs and cognitions and load tolerance through their thenar muscles. The worker was provided with clear rules for exercising with pain and commenced a progressive, strength-based exercise program in a gym-based environment. The worker reported they “loved the gym” and gained an enormous amount of self-confidence from “getting moving” again.  

Patient Outcomes:

Following the Axis Program, the worker reported significant reductions in pain and disability and was now attending gym independently. They no longer wore their thumb splint and were actively using their affected hand at home again. Objectively, their grip strength had improved from 6kg to 32kg!! Psychologically, the worker reported the biggest turning point for them was knowing it was safe to move into pain and that they weren’t doing themselves any further damage. With greater confidence, strength, and increased self-efficacy, we saw a full clearance for work duties achieved 3 weeks after completing the Axis Program.  

This is the greatest change to a worker’s trajectory of recovery I have ever seen. This worker had been recommended for, and was weeks away, from having a thumb fusion surgery. This surgery would have required further healing and recovery time, resulting in further deconditioning and time away from work. Furthermore, it would have likely resulted in the worker being unable to complete the inherent physical requirements of their job, ultimately requiring a career change (or worse, early retirement). Instead, within 2.5 months they had achieved a full clearance and reported renewed confidence in life activities, both at work and with their family. 

For me, this highlights the constant need to step back and look at the big picture with our clients and ask: “Is this current management plan going to get you where you need to go?”  If the answer to that question is uncertain, perhaps a fresh, conservative management opinion could help.   


Contact Axis to discuss our Pain Management and Functional Rehabilitation Programs or Screening Assessments.